Multiple Specialty Requested

I. Requested By
Name     Phone  
Company     Ext  
Address     Fax  
City     Email  
State      Zip  

II. Type of Review Requested
Second Opinion Examination    
Record Review    
Other (Specify Below)    
Specialty Requested:
Specialty Requested:
(Please Specify Below If Selected "Other")

III. Examinee Information
Last Name First Name
Address D.O.B.
City Employee ID Number
State Home Ph
Zip Work Ph  
Minor? No Gender  
Special Needs of Examinee:

IV. Clinical Information
Date of Onset: Reference #    
Condition Claimed (Include body part and CPT codes if available)  
 Type of Claim:
 
 Other (Please Specify)

V. Treating Provider
Name Specialty
Address Phone
City Fax
State Zip

VI. Employee Information (If Different from Examinee)
Last Name First Name
Address D.O.B.
City Employee ID Number
State Home Ph
Zip Work Ph  
Minor? No Gender  
 

VII. Please Have Independent Examiner Address the following issues:

Diagnosis?
Prognosis?
Causation of injury
Preexisting injuries
Further treatment reasonable, related, necessary?
Further diagnostic testing necessary?
Prior diagnostic testing reasonable and necessary?
Prior treatment reasonable, related, & necessary?
Any restrictions (work / daily living)?
Preaccident status reached?
Disability rating?
Other issues to be addressed (including additional information regarding loss)

6111 Broken Sound Parkway NW, #207, Boca Raton, FL 33487   T:877-463-9463   T:561-392-5001   F:561-392-5881